Bursae are sacs lined with a membrane similar to synovium they usually are located about joints or where skin, tendon, or muscle moves over a bony prominence.

may or may not communicate with a joint.

Function reduce friction, protect delicate structures from pressure.

4(No Transcript) 5

Bursae are similar to tendon sheaths and the synovial membranes of joints and are subject to the same disturbances (1) acute or chronic trauma, (2) acute or chronic pyogenic??? infection, and (3) low-grade inflammatory conditions such as gout, syphilis, tuberculosis, or rheumatoid arthritis.

Two types of bursae normally present (as over the patella and olecranon) and adventitious ones (such as develop over a bunion???, an osteochondroma????, or kyphosis?? of the spine). Adventitious bursae are produced by repeated trauma or constant friction?? or pressure.

Systemic causes, such as gout?? or syphilis??, and local trauma or irritants should be eliminated, and, when necessary, the patient's occupation or posture should be changed. One or more of the following local measures usually are helpful Rest, hot wet packs, elevation, and, if necessary, immobilization of the affected part.

8

Surgical procedures useful in treating bursitis are (1) aspiration and injection of an appropriate drug, (2) incision and drainage when an acute suppurative ???bursitis fails to respond to nonsurgical treatment, (3) excision of chronically infected and thickened bursae, and (4) removal of an underlying bony prominence.

9Carpal Tunnel Syndrome?????

(another name tardy median palsy) results from compression of the median nerve within the carpal tunnel. The syndrome consists predominantly of tingling?? and numbness in the typical median nerve distribution in the radial three and one-half digits (thumb, index, long, radial side of ring). Pain occurs diffusely in the hand and radiates up the forearm. Thenar?? atrophy usually is seen later in the course of the nerve compression.

innervated 10

The syndrome frequently is associated with nonspecific tenosynovial edema and rheumatoid tenosynovitis, as are trigger finger and de Quervain disease. Some studies reported biopsy specimens of the flexor tendon synovium from 21 patients with idiopathic??? carpal tunnel syndrome. The findings were similar in all and were typical of a connective tissue???? undergoing degeneration under repeated mechanical stress.

11Diagnosis

Paresthesia???? over the sensory distribution of the median nerve is the most frequent symptom it occurs more often in women and frequently causes the patient to awaken several hours after getting to sleep with burning and numbness of the hand that is relieved by exercise. The Tinel sign may be demonstrated in most patients by percussing?? the median nerve at the wrist. Atrophy to some degree of the median-innervated thenar muscles has been reported in about half of the patients treated by operation.

12

Acute flexion of the wrist for 60 seconds in some but not all patients or strenuous use of the hand increases the paresthesia. Application of a blood pressure cuff on the upper arm sufficient to produce venous distention may initiate the symptoms. Some studies evaluated the clinical usefulness of commonly administered provocative tests, including wrist flexion, nerve percussion, and the tourniquet test, in 67 hands with electrical proof of carpal tunnel syndrome and in 50 control hands.

13Diagnosis

The most sensitive test was the wrist flexion test, whereas nerve percussion was the most specific and the least sensitive. They also found that with the wrist in neutral position, the mean pressure within the carpal tunnel in patients with carpal tunnel syndrome was 32 mm Hg. This pressure increased to 99 mm Hg with 90 degrees of wrist flexion and to 110 mm Hg with the wrist at 90 degrees of extension. The pressures in the control subjects with the wrist in neutral position were 25 mm Hg, 31 mm Hg with the wrist in flexion, and 30 mm Hg with the wrist in extension.

14

Sensibility testing in peripheral nerve compression syndromes was investigated, found that threshold tests of sensibility correlated accurately with symptoms of nerve compression and electrodiagnostic studies.

15

Electrodiagnostic??? studies are reliable confirmatory tests. Ultrasonography???? has been used to show the movement of the flexor tendons within the carpal tunnel, but it does not clearly show soft tissue planes. Early reports of magnetic resonance imaging (MRI) in carpal tunnel syndrome are promising. A major advantage of MRI is its high soft tissue contrast, which gives detailed images of both bones and soft tissues. Care should be taken not to confuse this syndrome with nerve compression caused by a cervical disc herniation, thoracic outlet structures, and median nerve compression proximally in the forearm and at the elbow.

16Treatment

If mild symptoms have been present and there is no thenar muscle atrophy, the injection of hydrocortisone into the carpal tunnel may afford relief. Great care should be taken not to inject directly into the nerve. Injection also can be used as a diagnostic tool in patients without bony or tumorous blocking of the canal

17

65 of these cases probably are caused by a nonspecific synovial edema, and these seem to respond more favorably to injection. Injection also helps to eliminate the possibility of other syndromes, especially cervical disc or thoracic outlet syndrome. Some patients prefer to receive injections two or three times before a surgical procedure is carried out. If the response is positive and there is no muscle atrophy, conservative treatment with splinting and injection is reasonable.

18Treatment

If signs and symptoms are persistent and progressive, especially if they include thenar atrophy, division of the deep transverse carpal ligament is indicated. The results of surgery are good in most instances, and benefits seem to last in most patients.

19

Although thenar atrophy may disappear, it resolves slowly, if at all. As noted earlier, when symptoms of median nerve compression develop during treatment of an acute Colles fracture, the constricting bandages and cast should be loosened and the wrist should be extended to neutral position. When median nerve palsy develops after a Colles fracture and has gone unrecognized for several weeks, surgery is indicated without further delay.

20Lateral epicondylitis??????

Lateral epicondylitis (tennis elbow), a familiar term used to described a myriad of symptoms about the lateral aspect of the elbow, occurs more frequently in nonathletes than athletes, with a peak incidence in the early fifth decade and a nearly equal gender incidence.

Activities that require repetitive supination and pronation of the forearm with the elbow in near full extension.

21

Tenderness is present over the lateral epicondyle approximately 5 mm distal and anterior to the midpoint of the condyle. Pain usually is exacerbated by resisted wrist dorsiflexion and forearm supination, and there is pain when grasping objects. Plain roentgenograms usually are negative occasionally calcific tendinitis may be present. MRI demonstrates tendon thickening with increased T1 and T2 signals but generally is not indicated.

If prolonged (6 to 12 months), operative treatment may be considered it is effective in 90 of properly selected patients.

23

Adhesive Capsulitis

(frozen shoulder.)

????????

24

Frozen shoulders in patients who report no inciting event and with no abnormality on examination (other than loss of motion) or plain roentgenograms were designated as "primary," and those with precipitant traumatic injuries as "secondary." This division helps in planning treatment but does not necessarily predict outcome.

25

No formal inclusion criteria. There are no universally accepted criteria for the diagnosis of frozen shoulder. internal rotation frequently is lost initially, followed by loss of flexion and external rotation.

26

The incidence of frozen shoulder in the general population is approximately 2. (an increased incidence associated with, including diabetes mellitus (up to 5 times more), cervical disc disease, hyperthyroidism, intrathoracic disorders, and trauma). People between the ages of 40 and 70 are more commonly affected. Common to almost all patients is a period of immobility, the etiologies of which are diverse

27Primary Frozen Shoulder

Primary frozen shoulder is a vague entity that only rarely recurs in the same shoulder. The clinical course of primary (idiopathic) frozen shoulder consists of three phases.

Phase IPain. Patients usually have a gradual onset of diffuse shoulder pain, which is progressive over weeks to months. The pain usually is worse at night and is exacerbated by lying on the affected side. As the patient uses the arm less, pain leading to stiffness ensues.

28Primary Frozen Shoulder

Phase IIStiffness. Patients seek pain relief by restricting movement. This heralds the beginning of the stiffness phase, which usually lasts 4 to 12 months. Patients describe difficulty with activities of daily living men have trouble getting to their wallets and women with fastening brassieres. As stiffness progresses, a dull ache is present nearly all the time (especially at night), and this often is accompanied by sharp pain during range of motion at or near the new endpoints of motion.

29Primary Frozen Shoulder

Phase IIIThawing. This phase lasts for weeks or months, and as motion increases, pain diminishes. Without treatment (other than benign neglect) motion return is gradual in most but may never objectively return to normal, although most patients subjectively feel near normal, perhaps as a result of compensation or adjustment in ways of performing activities of daily living.

30Secondary Frozen Shoulder

Unlike patients with idiopathic frozen shoulder, patients with secondary frozen shoulder can recall a specific precipitating event, possibly related to overuse or injury. The three phases of classic frozen shoulder may not all be present and may not follow the previously outlined chronology fortunately, treatment for the two entities is similar.

31Diagnosis

tests in patients with a frozen shoulder (including plain film roentgenograms) usually are normal, except in those with medical disorders such as diabetes or thyroid disease. Bone scans have been reported to be positive in some patients.

Arthrograms characteristically show a reduced joint volume with irregular margins. Clinical improvement has been reported after arthrography because of brisement of adhesions from forcefully injecting fluid into the joint. A volume of less than 10 ml and lack of filling of the axillary fold currently are accepted arthrographic findings indicative of a frozen shoulder.

32Treatment

Traditionally, frozen shoulder has been considered a self-limiting condition, lasting 12 to 18 months.

Approximately 10 of patients have long-term problems. Patients seeking care earlier usually recover more quickly. Dominant shoulder involvement has been reported to be predictive of a good result, whereas occupation and treatment programs are not statistically significant. Obviously, the best treatment of frozen shoulder is prevention (secondary frozen shoulder), but early intervention is of paramount importance a good understanding of the pathological process by the patient and the physician also is important.

33Treatment

Initial treatment is nonoperative, with emphasis placed on control of pain and inflammation.

passive and active range-of-motion exercises. Abduction should be avoided initially to prevent impingement until joint motion becomes more supple.

34Treatment

Although a frozen shoulder usually is self-limiting and resolves in 12 to 18 months, many patients do not wish to wait that long for resolution of symptoms and request active intervention long before 12 months. With appropriate patient selection, significant improvement can be obtained in approximately 70 of patients.

Closed manipulation under anesthesia

Open release of contractures

35Treatment

Arthroscopic release is an option when closed manipulation fails or for patients who have had prolonged, recalcitrant adhesive capsulitis.

36Stenosing Tenosynovitis??????

more often in the hand and wrist than anywhere else in the body.

A peritendinitis may affect these tendons, causing pain, swelling, and crepitus??? .

37

When the long flexor tendons are involved, trigger thumb, trigger finger, or snapping finger occurs. The stenosis occurs at a point where the direction of a tendon changes, for here a fibrous sheath acts as a pulley?? , and friction is maximal. Although the tenosynovium lubricates the sheath, friction can cause a reaction when the repetition of a particular movement is necessary, as in winding a fine coil of wire?? or stacking laundry.

When the extensor pollicis brevis and the abductor pollicis longus tendons in the first dorsal compartment are affected, the condition is named after the Swiss physician, De Quervain, who described his experience in 1895.

Women are affected 10 times more frequently than men. The cause is almost always related to overuse, either in the home or at work, or is associated with rheumatoid arthritis. The presenting symptoms usually are pain and tenderness at the radial styloid. Sometimes a thickening of the fibrous sheath is palpable.

39diagnosisThe Finkelstein test usually is positive "on grasping the patient's thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is excruciating." Although Finkelstein states that this test is "probably the most pathognomonic objective sign," it is not diagnostic the patient's history and occupation, the roentgenograms, and other physical findings must also be considered. 40Treatment

Conservative treatment, consisting of rest on a splint and the injection of a steroid preparation into the tendon sheath, is most successful within the first 6 weeks after onset.

When pain persists, surgery is the treatment of choice (complete relief ).

41TRIGGER FINGER AND THUMB???????

Stenosing tenosynovitis, leading to inability to extend the flexed digit ("triggering") usually is seen after 45 years of age.

Patients may note a lump? or knot?? in the palm. The lump may be the thickened area in the first annular part of the flexor sheath, or a nodule or fusiform??? swelling of the flexor tendon just distal to it. The nodule can be palpated by the examiner's fingertip and will move with the tendon. The tendon nodule usually is at the entry of the tendon into the proximal annulus at the level of the metacarpophalangeal joint.

42

Treatment of trigger digits usually is nonoperative in the uncomplicated patient who presents a short time after onset of symptoms. Nonoperative methods include stretching, night splinting, and combinations of heat and ice. Corticosteroid injection is effective after one injection

Surgical release reliably relieves the problem for most patients

43Osteonecrosis of Femoral head????????

Osteonecrosis of the femoral head is a progressive disease that generally affects patients in the third though fifth decades of life if left untreated, it leads to complete deterioration of the hip joint. It is estimated that as many as 20,000 new cases of osteonecrosis are diagnosed each year in the United States.

44(No Transcript) 45(No Transcript) 46Diagnosis

Patients are typically asymptomatic early in the course of osteonecrosis and eventually have groin pain on ambulation. A thorough history and physical examination should be done to discover potential risk factors and determine the clinical status of the patient. Plain roentgenograms should be obtained including anteroposterior and lateral views. Roentgenographic changes seen in osteonecrosis depend on the stage of the disease. Plain films may appear normal in the early stages, but changes are noted as the disease progresses, such as increased density or lucency in the femoral head.

47

Advances in MRI have made earlier diagnosis of osteonecrosis of the femoral head possible and allow determination of the exact stage and extent of the pathological process without use of invasive methods.

48Treatment

Core decompression

Bone Grafting

Vascularized Fibular Grafting

Osteotomies of Proximal Femur

49

Resurfacing Hemiarthroplasty

Total Hip Arthroplasty and Bipolar Hemiarthroplasty.

Improved results recently have been reported with modern cementing techniques and press-fit cementless total hip arthroplasty in patients with osteonecrosis. With new bearing surfaces becoming available, such as ceramic on ceramic, metal on metal, and highly cross-linked polyethylene, results may improve even more. The results of primary total joint replacement for osteonecrosis are now approaching those reported for osteoarthritis in aged-matched patients.

The terms osteochondrosis and epiphysitis designate disorders of actively growing epiphyses. The disorder may be localized to a single epiphysis or occasionally may involve two or more epiphyses simultaneously or successively. The cause generally is unknown, but evidence indicates a lack of vascularity that may be the result of trauma, infection, or congenital malformation.

54Treatment

Surgery rarely is indicated for Osgood-Schlatter disease

the disorder usually becomes asymptomatic without treatment or with simple conservative measures such as the restriction of activities or cast immobilization for 3 to 6 weeks. In a review of the natural history of untreated Osgood-Schlatter disease in 69 knees in 50 patients, found that 76 of patients believed they had no limitation of activity, although only 60 could kneel without discomfort.

55

In a prospective study of 17 patients with Osgood-Schlatter disease and 12 adolescents without anterior knee pain, Aparicio et al. noted a strong association between Osgood-Schlatter disease and patella alta. The increase in patellar height may require an increase in the force by the quadriceps to achieve full extension, which could be responsible for the apophyseal lesion. However, it can be argued that the patella alta is the result of chronic avulsion of the bony tuberosity.

56

Surgery may be considered if symptoms are persistent and severely disabling.

Complications reported of Osgood-Schlatter disease whether treated surgically or not, including subluxations of the patella, patella alta, nonunion of the bony fragment to the tibia, and premature fusion of the anterior part of the epiphysis with resulting genu recurvatum.

57Insertion of Bone Pegs

Incise the periosteum longitudinally distal to the tuberosity. With an electric saw cut two matchstick pegs 4 cm long from the tibia make the base of each peg larger than its tip. Then drill two holes through the tibial tuberosityone near but not in contact with the proximal tibial physis and slanting proximally and laterally and the other also distal to the physis and slanting proximally and medially. Insert the pegs into these holes and resect their projecting ends.

58

technique for insertion of bone pegs for Osgood-Schlatter disease

AFTERTREATMENT. A cast is applied from groin to toes and is worn for 2 weeks. A cylinder walking cast is then worn for 4 more weeks.

59Excision of Ununited Tibial Tuberosity

TECHNIQUE Make a longitudinal incision centered over the tibial tuberosity. Expose the patellar tendon and incise it longitudinally. Elevate the tendon laterally and medially and excise any loose fragments of bone and enough tibial cortex, cartilage, and cancellous bone to remove any bony prominence completely. Do not disturb the peripheral and distal margins of the insertion of the patellar tendon. Close the wound.

AFTERTREATMENT. A cylinder walking cast is applied and worn for 2 to 3 weeks. Exercises are then begun.

classified patients with this disease into groups according to the amount of involvement of the capital femoral epiphysis

group I, partial head or less than half head involvement

groups II and III, more than half head involvement and sequestrum formation

group IV, involvement of the entire epiphysis.

64

They noted certain roentgenographic signs described as "head at risk" correlated positively with poor results, especially in patients in groups II, III, and IV.

These head-at-risk signs include

Lateral subluxation of the femoral head from the acetabulum,

Speckled calcification lateral to the capital epiphysis,

Diffuse metaphyseal reaction (metaphyseal cysts),

A horizontal physis,

Gage sign, a radiolucent V-shaped defect in the lateral epiphysis and adjacent metaphysis.

65

Containment by femoral varus derotational osteotomy for older children in groups II, III, and IV with head-at-risk signs.

Contraindications include an already malformed femoral head and delay of treatment of more than 8 months from onset of symptoms.

Surgery is not recommended for any group I children or any child without the head-at-risk signs.

66

Salter and Thompson advocated determining the extent of involvement by describing the extent of a subchondral fracture in the superolateral portion of the femoral head. If the extent of the fracture (line) is less than 50 of the superior dome of the femoral head, the involvement is considered type A, and good results can be expected. If the extent of the fracture is more than 50 of the dome, the involvement is considered type B, and fair or poor results can be expected.

67

According to Salter and Thompson, this subchondral fracture and its entire extent can be observed roentgenographically earlier and more readily than trying to determine the Catterall classification. Furthermore, according to these authors, if the femoral head is graded as type B, then probably an operation such as an innominate osteotomy should be carried out. After statistical analysis of 116 hips affected with Perthes disease, Mukherjee and Fabry concluded that Salter and Thompson's classification is simple and accurate and can be applied early in the course of the disease to determine management.

68

Conclusions

1. Most patients can be treated by noncontainment methods and obtain good results (84).

3. The Catterall classification is a valid indicator of results but is not applicable as a therapeutic guide.

4. Head-at-risk signs added little to the Catterall classification as a prognostic indicator or therapeutic guide.

5. All of the fair and poor results were in patients with Catterall III or IV involvement and onset of the disease at age 6 or later.

69Injury of Meniscus?????

The menisci are crescents, roughly triangular in cross section, that cover one half to two thirds of the articular surface of the corresponding tibial plateau

70TEARS OF MENISCI

Traumatic lesions of the menisci are produced most commonly by rotation as the flexed knee moves toward an extended position. The medial meniscus, being far less mobile on the tibia, can become impaled between the condyles, and injury can result. The most common location for injury is the posterior horn of the meniscus, and longitudinal tears are the most common type of injury.

71

The length, depth, and position of the tear depend on the position of the posterior horn in relation to the femoral and tibial condyles at the time of injury. Menisci with peripheral cystic formation or menisci that have been rendered less mobile from previous injury or disease may sustain tears from less trauma.

72

Congenital anomalies of the menisci, especially discoid lateral meniscus, may predispose to either degeneration or traumatic laceration. Likewise, areas of degeneration that develop as a result of aging cannot withstand as much trauma as healthy fibrocartilage. Abnormal mechanical axes in a joint with incongruities or ligamentous disruptions expose the menisci to abnormal mechanics and thus can lead to a greater incidence of injury.

73Classification

Numerous classifications of tears of the menisci have been proposed based on location or type of tear, etiology, and other factors most of the commonly used classifications are based on the type of tear found at surgery. (1) longitudinal tears(bucket handle tears), (2)body tears, (3)anterior horn tears, (4)1/3 anterior tears, (5)1/3 posterior tears, and (6) horizontal tears

Cysts of the menisci are frequently associated with tears and are 9 times more common on the lateral than on the medial side. The most common cause is trauma that produces degeneration and secondary mucinous and cystic changes in the periphery of the meniscus

77

Discoid menisci are abnormal, and because of hypermobility and the bulk of the tissue between the articular surfaces, they are vulnerable to compression and rotary stresses. Degeneration within the discoid meniscus, as well as tears, may develop. The diagnosis often is not made until surgery, since the discoid meniscus may not produce significant symptoms until some derangement of the meniscus occurs.

78Diagnosis

The diagnosis of internal derangement of the knee caused by a meniscal tear can be difficult even for an experienced orthopaedic surgeon. Using a careful history and physical examination and supplementing standard roentgenograms in specific instances with special imaging techniques and arthroscopy can keep errors in diagnosing tears of the menisci to less than 5.

79

When a meniscus has been injured, capsular and ligamentous structures, as well as the articular surfaces, often have been injured also.

Disorders that can produce symptoms similar to those of a torn meniscus must be kept in mind, and to avoid error, a detailed, careful, systemic history and physical examination supplemented with appropriate imaging studies and arthroscopy are indicated, especially if symptoms and findings are not quite typical of a torn meniscus.

80

A history of specific injury may not be obtained, especially when tears of abnormal or degenerative menisci have occurred. This scenario is noted most often in a middle-aged person who sustains a weight-bearing twist on the knee or who has pain after squatting. Tears of normal menisci usually are associated with more significant trauma or injury but are produced by a similar mechanism, as the meniscus is entrapped between the femoral and tibial condyles in flexion, tearing as the knee is extended.

81

Patients with tears in degenerative menisci may recall symptoms of mild catching, snapping, or clicking, as well as occasional pain and mild swelling in the joint. Once the tear in the meniscus becomes of significant size, more obvious symptoms of giving way and locking may develop.

82

The syndromes caused by tears of the menisci can be divided into two groups those in which there is locking and the diagnosis is clear and those in which locking is absent and the diagnosis is more difficult. The injured knee can be locked and still extend to neutral position. Locking usually occurs only with longitudinal tears and is much more common with bucket handle tears, usually of the medial meniscus.

83Locking of the knee

May be caused by

a bucket handle tear of a meniscus

an intraarticular tumor

an osteocartilaginous loose body

other conditions

Regardless of its cause, locking that is unrelieved after aspiration of the hemarthrosis and a period of conservative treatment may require surgical treatment.

84

No locking

A patient typically gives a history of several episodes of trouble referable to the knee, often resulting in effusion and a brief period of disability but no definite locking. A sensation of "giving way" or snaps, clicks, catches, or jerks in the knee may be described, or the history may be even more indefinite, with recurrent episodes of pain and mild effusion in the knee and tenderness in the anterior joint space after excessive activity.

85

When well understood, the following clues can be important in the differential diagnosis in this second group a sensation of giving way, effusion, atrophy of the quadriceps, tenderness over the joint line (or the meniscus), and the reproduction of a click by manipulative maneuvers during the physical examination.

86Diagnostic Tests

Clicks or snaps, either audible or detected by palpation during flexion, extension, and rotary motions of the joint, can be valuable for diagnosis, and efforts should be made to reproduce and accurately locate them. If these noises are localized to the joint line, the meniscus most likely contains a tear. Similar noises originating from the patella, the quadriceps mechanism, or the patellofemoral groove must be differentiated.

87

Numerous manipulative tests have been described, but the McMurray test and the Apley grinding test probably are most commonly used. All basically involve attempts to locate and reproduce crepitation that results as the knee is manipulated.

88

The McMurray test

With the patient supine and the knee acutely and forcibly flexed, the examiner can check the medial meniscus by palpating the posteromedial margin of the joint with one hand while grasping the foot with the other hand. Keeping the knee completely flexed, the leg is externally rotated as far as possible and then the knee is slowly extended. As the femur passes over a tear in the meniscus, a click may be heard or felt. The lateral meniscus is checked by palpating the posterolateral margin of the joint, internally rotating the leg as far as possible, and slowly extending the knee while listening and feeling for a click.

89

A click produced by the McMurray test usually is caused by a posterior peripheral tear of the meniscus and occurs between complete flexion of the knee and 90 degrees. Popping, which occurs with greater degrees of extension when definitely localized to the joint line, suggests a tear of the middle and anterior portions of the meniscus. Thus the position of the knee when the click occurs may help locate the lesion. A positive McMurray click localized to the joint line is additional evidence that the meniscus is torn a negative McMurray test does not rule out a tear.

90Grinding test

Described by Apley

With the patient prone, the knee is flexed to 90 degrees and the anterior thigh is fixed against the examining table. The foot and leg are then pulled upward to distract the joint and rotated to place rotational strain on the ligaments when ligaments have been torn, this part of the test usually is painful. Next, with the knee in the same position, the foot and leg are pressed downward and rotated as the joint is slowly flexed and extended when a meniscus has been torn, popping and pain localized to the joint line may be noted. Although the McMurray, Apley, and other tests cannot be considered diagnostic, they are useful enough to be included in the routine examination of the knee.

91Imaging Studies

Roentgenograms. AP, lateral, and intercondylar notch views with a tangential view of the inferior surface of the patella should be routine. Ordinary roentgenograms will not confirm the diagnosis of a torn meniscus but are essential to exclude osteocartilaginous loose bodies, osteochondritis dissecans, and other internal derangements that can mimic a torn meniscus.

92Other Diagnostic Studies

such as ultrasonography, scintigraphy, computed tomography (CT), and magnetic resonance imaging (MRI), have been shown to improve diagnostic accuracy in many knee disorders. Their principal attractiveness over arthrography or arthroscopy is that they are noninvasive procedures.

Arthroscopy has made the diagnosis of acute meniscal injuries more precise, which aids in the treatment planning. Incomplete tears or small peripheral tears are difficult to confirm without arthroscopy.

Many incomplete tears will not progress to complete tears if the knee is stable. Small stable peripheral tears have been observed to heal after 3 to 6 weeks of protection.

95

Chronic tears with a superimposed acute injury cannot be expected to heal with nonoperative treatment. Thus an acute meniscal injury in a patient with a history of symptomatic episodes such as catching, locking, and giving way probably does not qualify for nonoperative management.

Nonoperative treatment is never appropriate in a patient with a locked knee caused by a bucket handle tear of the meniscus. Forceful manipulation of such displaced tears is never justified, and most will not heal without surgery even if reduced.

96

Meniscal tears that cause infrequent and minimal symptoms can be treated with rehabilitation and restricted activity. Tears associated with ligamentous instabilities can be treated nonoperatively if the patient defers ligament reconstruction or if reconstruction is contraindicated.

Chronic tears even within the vascularized zone will not heal without surgery. However, chronic tears have been shown to heal when the synovial bed of the meniscus has been freshened and the torn edges have been apposed and sutured.

97

The most important aspect of nonoperative treatment, once the acute pain and effusion have subsided, is restoration of the power of the muscles about the injured knee to a level comparable with that of the opposite knee. As much motion of the joint as possible should be encouraged. This can be accomplished through a regular program of progressive exercises, not only for the quadriceps and hamstrings but also for the hip flexors and abductors.

98OPERATIVE MANAGEMENT

The indications and surgical techniques for excision of torn menisci have been controversial noted orthopaedic surgeons have advocated total excision of the torn meniscus, whereas others have proposed subtotal excision. Justification for total excision often was based on short-term, functional recovery criteria. When longer follow-up was studied, increasing degenerative changes were noted, especially after total meniscectomy was performed. Degenerative changes probably caused by biomechanical changes were directly proportional to the amount of meniscus excised. In vitro that removal of even one third of the meniscus increased the joint contact forces by up to 350.

99

The greatest degenerative changes in animals occurred after total rather than subtotal meniscectomy. These changes also have been observed arthroscopically in human knees. After subtotal excision of the meniscus, less articular cartilage degeneration was found, and it was localized principally to the area previously covered by the meniscus. The amount of degenerative change in the articular cartilage was directly proportional to the amount of meniscus removed.

If a significant portion of the peripheral rim can be retained by subtotal meniscal excision, the long-term result is improved.

100

Complete removal of the meniscus is justified only when it is irreparably torn, and the meniscal rim should be preserved if at all possible. Total meniscectomy is no longer considered the treatment of choice in young athletes or other people whose daily activities require vigorous use of the knee.

101

Excision of only the torn portion of the meniscus, either by open arthrotomy or by arthroscopic technique, has sufficient support and clinical results to indicate its routine use. Subtotal excision of a torn meniscus by open arthrotomy can be a difficult procedure and can be accomplished more easily by arthroscopic techniques.

102(No Transcript) 103Late Changes after Meniscectomy(????????????)

The knee can function well without the meniscus, sometimes for the rest of a patient's life, but late degenerative changes within the joint sometimes occur, and the loss of the meniscus undoubtedly plays some part in producing these changes. In addition to the condition of the meniscus, numerous other factors can influence long-term function, such as joint alignment, laxity of the capsular or ligamentous structures, and incomplete rehabilitation of the musculature about the knee.

104

????!

Thank you very much for your attention!

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